INCONTINENCE OF URINE

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INCONTINENCE OF URINE
Dr .Ashraf Fouda Damietta General Hospital
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Physiology of Micturition

• Bladder innervation
• somatic, parasympathetic (PSN) and sympathetic
  (SNS)
• As urine fills the bladder, the detrusor
  stretches and allows the bladder to expand
• 300 ml in bladder before the brain
• recognizes bladder fullness

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Physiology of Micturition
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Physiology of Micturition

• Low bladder volumes SNS is stimulated and PNS
  is inhibited
• Bladder full PNS stimulated (bladder
  contracts) SNS inhibited (internal sphincter
  relaxes)
• Intravesical pressure gt resistance within the
  urethra urine flows
• Pudenal nerve innervates external sphincter

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DEFINITION OF INCONTINENCE OF URINE

• It is involuntary escape of urine

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TYPES

• 1. True incontinence.
• 2. False incontinence (ischuria paradoxica).
• 3. Stress or sphincter incontinence.
• 4. Urgency incontinence
• (precipitancy-detrusor instability or detrusor
  dyssynergia).
• 5. Nocturnal enuresis.

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1. True (continuous) incontinence

• In this case, urine escapes continuously by day
  and by night.
• It is caused by
• (a) Urinary fistulae as vesicovaginal fistula
• (b) Ectopia vesica.

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2. False incontinence (Overflow
incontinence)

• It is involuntary loss of urine following
  overdistension of the bladder.
• Overflow incontinence, usually short-term, can
  occur after vaginal deliveryespecially if
  epidural anesthesia was used.
• Other causes include diabetes, neurological
  diseases, severe genital prolapse, and post
  surgical obstruction.

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4. Urgency incontinence (precipitancy-detrusor
instability or detrusor dyssynergia).

• The woman feels the desire to micturate but
  before she reaches the bathroom, urine passes
  involuntarily.
• It is due to irritability of the bladder muscle
  and so the patient cannot inhibit it.
• It is due to
• emotional disturbance,
• neurologic diseases, and
• bladder diseases as cystitis, stone or tumour.

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Detrusor instability (DI)

• Detrusor instability, also called overactive
  bladder, is a condition in which the bladder
  contracts involuntarily in response to filling.
• It was called detrusor dys-synergia in the past.
• It commonly presents as urge incontinenceleakage
  of urine associated with a strong desire to void.
  
• No cause is identified in more than 90 of these
  patients.
• Advancing age is an important risk factor.

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Detrusor instability (DI)

• Detrusor instability caused by neurologic
  diseases such as cerebrovascular disease,
  multiple sclerosis, or spinal cord injury is
  called detrusor hyperreflexia.
• Irritation of the bladder by inflammation (such
  as urinary tract infection) or prior pelvic
  surgery can also cause detrusor instability.

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Urge incontinence
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STRESS INCONTINENCE )SPHINCTER
INCONTINENCE-GENUINE STRESS INCONTINENCE)
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DEFINITION

• It is involuntary escape of few drops of urine
  with increased intra-abdominal pressure as during
  straining, sneezing, coughing, laughing ... etc.

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DEGREES OF STRESS INCONTINENCE

• Grade I
• Incontinence occurs only with severe stress, such
  as coughing, sneezing, etc
• Grade II
• Incontinence with moderate stress, such as rapid
  movement or walking up and down stairs
• Grade III
• Incontinence with mild stress, such as standing.
  The patient is continent in the supine position

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PHYSIOLOGICAL ANATOMY

• The bladder neck and upper third or half of the
  urethra are above the level of the pelvic floor.

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PHYSIOLOGICAL ANATOMY

• With increased intra-abdominal pressure,
  the pressure is equally transmitted to the
  bladder and upper urethra and urine will not
  escape

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The internal urethral sphincter (
bladder sphincter)

• Is an involuntary muscle which surrounds the
  bladder neck.

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The external urethral sphincter

• is a voluntary muscle found between the
  superficial and deep perineal membranes and
  surrounds the middle part of the urethra
  (compessor urethrae muscle).

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The external urethral sphincter

• It empties the urethra after the act of
  micturition,
• Interrupts the flow of urine on desire
  and
• It acts as a secondary defensive mechanism
  against escape of urine.

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• At rest the urethra makes an angle of 90-100
  degrees with the base of the urinary bladder
  called the
  posterior urethrovesical angle.
• The urethra also makes an angle of
  less than 30 degrees with the vertical line.

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During micturition the following changes occur

• 1. Descent of the bladder neck with complete loss
  of the posterior urethrovesical angle (angle
  becomes 180 degrees).
• 2. Opening (funneling) of the bladder neck and
  upper urethra.
• 3. Descent of the urethra leading to increase in
  the angle between it and vertical line, so the
  angle becomes more than 30 degrees.
• . In stress incontinence, one or all of the above
  changes occur with increased intra-abdominal
  pressure.

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Incidence of Subtypes of Urinary Incontinence in
Women

• Stress Incontinence 50
• Urge Incontinence 20
• Mixed 30

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TYPES OF STRESS INCONTINENCE

• Type 1 There is complete loss of the posterior
  urethrovesical angle.
• Type 2 There is complete loss of the posterior
  urethrovesical angle together with increase in
  the angle between the urethra and vertical line
  to be more than 30 degrees.
• This type leads to severe stress incontinence

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AETIOLOGY

• It is due to either
• Weakness of the internal urethral sphincter or
• Descent of bladder neck below the level of the
  pelvic floor.

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AETIOLOGY

• 1. Congenital weakness of the internal urethral
  sphincter, seen in the young nullipara.
• 2. Congenital defects as
• Epispadias,
• Short urethra (less than 1 cm),
• Wide bladder neck, and
• Separation of symphysis pubis.

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AETIOLOGY

• 3. Trauma to the region of the bladder neck due
  to vaginal delivery or operation.
• The incidence of stress incontinence increases
  with parity due to repeated birth trauma.

In fact vaginal delivery is the commonest cause
of stress incontinence.
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AETIOLOGY

• 4. Menopause Lack of oestrogen leads to atrophy
  of bladder neck supports.
• 5.Pregnancy and continuous administration of
  oestrogen-progestogen preparation to induce
  psuedopregnancy state to treat endometriosis.
• The hormonal imbalance with increased
  progesterone weakens the internal urethral
  sphincter.

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AETIOLOGY

• 6. Genital prolapse
• If the bladder neck descends below the level of
  the pelvic floor, the increased intra-abdominal
  pressure will be transmitted to the bladder and
  not to the upper urethra leading to escape of
  urine.
• 7. Organic nervous diseases
  as disseminated sclerosis.

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Pathophysiology of Stress Incontinence

• The basic pathology is urethral incompetence.
• This can be either due to
• A) Urethral hypermobility (80 - 90 of
  patients)
• B) Intrinsic Sphincter Dysfunction (10 - 20 of
  patients)

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A) Urethral hypermobility (80 -
90 of patients)

• This results from loss of the normal pelvic
  support mechanism of the bladder and urethra due
  to
• Trauma and stretching of vaginal delivery
• Hysterectomy
• Hormonal changes ( Menopause)
• Pelvic denervation
• Congenital weakness

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A) Urethral hypermobility (80 -
90 of patients)

• As the bladder neck support is weakened, the
  increase in intra-abdominal pressure is no longer
  transmitted equally to the bladder outlet, and
  therefore instantaneous leakage occurs.

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B) Intrinsic Sphincter Dysfunction (10 - 20 of
patients)

• This results from damage to the sphincter due to
• Multiple prior operations
• Trauma
• Radiation
• Neurogenic disorders including Diabetes Mellitus
  
• Atrophic changes lack of estrogen.  

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Diagnosis
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A. History

• A detailed history differentiates between the
  different types of incontinence.
• Stress incontinence and detrusor instability
  frequently occur together.
• Gradual onset after menopause suggests oestrogen
  deficiency.
• History of vaginal repair or operation in the
  region of the bladder neck and history of any
  neurologic disease.

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B. Diagnostic Tests
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1. Stress Test

• The bladder must be moderately full.
• The patient in the lithotomy position, the two
  labia are separated, and the patient is asked to
  cough.
• If urine escapes, the patient is incontinent.
• If no urine escapes, the test is repeated while
  the index and middle fingers in the vagina press
  on the perineum to abolish reflex contraction of
  the levator ani muscles during straining.
• If still no urine escapes, the test is repeated
  while the patient is standing with the legs
  separated.

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2. Bonney test

• It is indicated in case of a positive stress test
  associated with a cystocele.
• To know if incontinence is due to descent of
  bladder neck or weakness of the sphincter.
• The index and middle fingers are placed on both
  sides of the urethra to elevate the bladder neck
  upwards.
• If no urine escapes on stress it means that the
  incontinence is due to descent of the bladder
  neck, but if urine still escapes it means
  weakness of the sphincter.

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3. Yousef Test

• Indicated in case of a negative stress test
  associated with a large cystocele to diagnose
  hidden stress incontinence.
• The cystocele is reduced, the cervix is grasped
  with a volsellum and pushed upward, then the
  patient is asked to cough.
• If urine escapes, it indicates that the patient
  was continent because of kinking of the urethra.

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4. Examination of Urine

• Urinalysis, culture and sensitivity to exclude
  cystitis.

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5. Cystourethroscopy

• To exclude lesions in the urethra and bladder.
• The bladder neck is examined.
• It should close in response to straining.
• However, it opens in case of stress incontinence.

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6. Cystourethrography

• A radio-opaque dye is injected by a catheter into
  the bladder.
• On straining, the lateral view will show absence
  of the posterior urethrovesical angle in more
  than 90 of cases.
• Funneling of the bladder neck in the
  antero-posterior view may be seen in some cases.
• The procedure is recorded on video tape (video
  Cystourethrography) to facilitate diagnosis and
  for education purposes.

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7. Urodynamics

• Medical science concerned with the study of urine
  transport from kidney to bladder as well as its
  storage and evacuation
• Classification
• 1.Cystometrogram( most important test), Filling
  Cystometry and Voiding Cystometry
• 2.Urethral pressure profile
• 3.Uroflow
• 4.Electromyography

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Cystometrogram

• To measure the intravesical pressure while the
  bladder is filled with sterile water or carbon
  dioxide gas.
• It diagnoses stress incontinence and detrusor
  instability.
• The most important test.

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Cystometrogram

• Involves filling the bladder to measure
  volume-pressure relationships.
• As the bladder is filled to its normal capacity
  of 300-500 ml, the pressure inside the bladder
  should remain low.
• The patient usually experiences the first urge to
  void at 150-200 ml.

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Cystometrogram

• Patients with DI often have reduced bladder
  capacity (lt 300 ml) and demonstrate
  urinary incontinence that is associated with
  involuntary bladder contractions
  (pressure increase above baseline)

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Cystometrogram

• In patients with GSI, incontinence is
  demonstrated when the patients coughs or strains
  (e.g., Valsalva maneuver).
• The intravesical pressure at which leakage is
  noted (leak point pressure) is generally lt 60 cm
  of water pressure if intrinsic sphincter
  deficiency is present.

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8. The Cotton-Tip Applicator (Q-Tip)
Test

• A sterile applicator with a small piece of cotton
  at its tip is introduced to reach the bladder
  neck.
• The angle between the applicator and the
  horizontal is measured.
• The patient then strains maximally using the
  Valsalva manoeuvre.
• This causes descent of the bladder neck and
  upward movement of the applicator producing a new
  angle with the horizontal.

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(Q-Tip) Test

• In normal patients the increase in the angle is
  less than 30 degrees.
• In stress incontinence the change is more than 30
  degrees indicating poor support and abnormal
  descent of bladder neck
• The test is positive in more than 90 of cases
  with stress incontinence.

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9. Measurement of Urethral Pressure

• To maintain continence, the urethral pressure
  (100-120 cm water) must be higher than the
  intravesical pressure (0-20 cm water).
• A special catheter is used which measures the
  intravesical and intra-urethral pressure.

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• The urethral closing pressure
• Equals the intraurethral pressure minus the
  intravesical pressure (normally 90-100 cm water).
  
• The length of the urethra along which urethral
  pressure exceeds bladder pressure is termed
  functional length of the urethra which is 3-4 cm.
  
• In stress incontinence the urethral closing
  pressure is reduced.

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10. Measurement of Urethral Length

• Stress incontinence occurs if the length is less
  than 1 cm.

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11. Uroflowmetry

• It records the rate of urine flow through the
  urethra when the patient is asked to void
  spontaneously while sitting on uroflow chair.
• It is used to evaluate patients with stress
  incontinence before surgery to exclude difficulty
  in voiding which may be increased by bladder neck
  surgery.

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• The normal female voids by the rule of "20"
• that is urine is passed at a rate of 20 ml/second
  and the bladder is emptied in less than 20
  seconds.

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12. Sonographic

• It gives information about funneling of the
  bladder neck, both at
  rest and with Valsalva manoeuvre.

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By three-dimension transvaginal ultrasound

• The continent women have a thick wall internal
  urethral sphincter which extends from the bladder
  neck and along 60-80 of the whole urethra.
• In stress incontinence, the sphincter is torn as
  proved by appearance of areas of echolucency.

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By three-dimension transvaginal ultrasound

• When rupture affects the upper part of the
  sphincter, the urethra appears
  "funnel-shaped".
• When damage affects the lower part, the urethra
  appears "vase-shaped".
• When rupture affects the whole length of the
  sphincter, the urethra appears short and
  irregular.

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What laboratory tests are helpful in evaluating
incontinence?

• Postvoid residual is an easy initial test to
  obtain.
• After the patient voids, there should be less
  than 50 ml of urine in the bladder.
• Postvoid residual is measured by ultrasound or
  catheterizing the patient in the office.
• A patient with an elevated Postvoid residual
  (repeat measurements greater than 100-200 ml) may
  have an underlying neurologic disorder.

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What laboratory tests are helpful in evaluating
incontinence?

• Catheterization also provides a good opportunity
  to obtain urine for analysis and culture.
• Urinalysis and urine culture help to diagnose
  urinary tract infection.
• Blood work is required only if compromised renal
  function, diabetes, syphilis, or other systemic
  diseases are suspected.

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Which tests are most helpful in differentiating
between GSI and DI?

• Cystometrogram
• Cystoscopy
• should be performed especially in patients with
  irritative bladder symptoms such as urgency,
  frequency, and hematuria
• To rule out
• inflammation,
• tumors, or
• anatomic deformities

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TREATMENT
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I. Prophylactic Treatment

• 1. During labour, the bladder should be kept
  empty.
• 2. Episiotomy is performed if necessary.
• 3. Physiotherapy.
• Pelvic floor exercises are started after
  delivery.
• These include repeated stoppage of the urinary
  stream during micturition and repeated
  contractions of the pelvic floor muscles.

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II. Conservative (non-surgical) Treatment

• Indications
• 1.Mild stress incontinence.
• 2.The patient not completed her family as vaginal
  delivery may damage a bladder neck repair
• 3.Patient is unfit for surgery or refuses
  surgery.
• 4.When stress incontinence is combined with
  detrusor instability.
• The latter should be treated at first before
  surgery is done for stress incontinence.

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Conservative treatment cures or improves 50 of
cases and include

• 1. Physiotherapy Kegl perineometer may be used.
• 2. Faradic current stimulation of the levator ani
  muscles to improve their tone.
• 3. Vaginal cones
• A set consists of 5 or 9 cones.
• Weight ranges from 20 to 100 grams.
• Patient inserts the cone in the vagina and keeps
  it for 15 minutes twice daily.
• If this succeeds she inserts the next cone.
• This improves the tone of the pelvic floor
  muscles.

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Conservative treatment cures or improves 50 of
cases and include

• 4.Oestrogen therapy for menopausal patients
• It causes thickening of the urethral mucosa and
  engorgement of the underlying blood vessels thus
  increasing the urethral pressure and resistance.
• Oestrogen is given orally or as vaginal cream.
• 5. Alpha-adrenergic stimulants
  which stimulate contraction of the internal
  urethral sphincter, e.g. ephedrine.
• 6.Large vaginal diaphragms, Hodge pessary to
  elevate ' and support the bladder neck.

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Conservative treatment cures or improves 50 of
cases and include

• 7. Reduction of weight in obese patients to
  reduce intra-abdominal pressure.
• 8. Stop caffeine (to avoid diuresis) and smoking
  (to avoid coughing)
• 9. Injection of Teflon or bovine collagen in the
  submucosal layer in the region of the bladder
  neck.
• This leads to narrowing of the urethral lumen and
  increased urethral resistance.

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Il. Surgical Treatment

• It is the primary treatment of stress
  incontinence.
• The operation is done vaginally, abdominally, or
  abdominovaginally.
• Almost 200 operations have been described.

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• Urehroplasty (Kelly,Kennedy,etc.)
• Urethropexy (Retropubic urethropexy e.g.
  Marchall-Marchitti-Krantz, etc.)
• Colposuspension ( Burch operation, Preyera ,
  etc.)
• Urethral slings (Aldridge operation, etc..)
• Tension free Vaginal Tape (TVT)

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A. Vaginal Operations
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1. Kelly operation 1914

• It consists of repair of cystocele and/or
  urethrocele.
• Vertical mattress sutures are then placed to
  plicate the whole urethra and bladder neck.
• This gives support to the urethra and restores
  the normal posterior urethrovesical angle.
• Operation is done for mild and moderate cases of
  stress incontinence.
• Long term success rate is 55-65.

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2. El-Hemaly urethrorrhaphy operation

• A vertical incision is made in the anterior
  vaginal wall.
• The torn edges of the internal urethral sphincter
  are sutured together to restore its integrity.
• The repair restores the normal urethrovesical
  angles seen in continent women.

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3. Vaginal tape operation (TVT)1996

• The tape is made of prolene and has a curved
  needle at each end.
• Operation is done using local infiltration
  anaesthesia.
• Two small transverse incisions 5 cm apart are
  made in the suprapubic area.
• A vertical incision is made in the anterior
  vaginal wall.
• The needles of the tape are passed upward behind
  the pubic bone and brought out through the
  suprapubic incisions.
• The tape is made to surround the mid-urethra.

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3. Vaginal tape operation (TVT)

• The cystoscope is used by the assistant to make
  sure that the bladder is not pierced by the
  needle.
• The tape is adjusted by pulling on its ends, and
  continence is confirmed by asking the patient to
  cough.
• The ends of the tape are cut off and left free
  and not fixed to the tissues,
• Finally the vaginal and suprapubic incisions are
  closed.
• When stress occurs ,the recti will contract and
  pull on the tape to support the urethra and
  prevent escape of urine

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Tension free Vaginal Tape (TVT)

• Simple, easy, relatively safe with short recovery
  little pain.
• Reported cure is 86 improvement is 11.
• Operation takes 20-30 minutes.
• Complications urine retention, parautrethral
  paravesical hemorrhage, infection , bladder
  bowel injury.

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B. Abdominal Operations
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1. Mashall-Marchetti-Krantz 1949

• The stitches are placed in the fascia on each
  side of the bladder neck and upper half of the
  urethra and are attached to the periosteum on the
  back of the symphysis pubis.
• This restores the normal intra-abdominal position
  of the urethra.
• Main complication is osteitis pubis (0.5-5).
• Nonabsorpable (as mersilene) or delayed
  absorbable sutures (as Vicryl or Dexon) are used.

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2. Burch Operation 1968

• Burch colposuspension is the operation of choice.
  
• It corrects both stress incontinence and
  cystocele.
• The stitches are placed in the fascia on each
  side of the bladder neck and the base of the
  bladder and are attached to the iliopectineal
  ligaments (Cooper Ligaments),
  (The
  pectineal part of the inguinal ligament)
• Nonabsorpable or delayed absorbable sutures are
  used.
• Operation can be done through the laparoscope.

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• The success rate of the above abdominal
  operations is 80-90

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C. Combined Abdomino vaginal Operations
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1. Urethral Slings

• In this condition, there is damage or paralysis
  of the sphincteric unit which could even be in a
  normal position.
• The goal of surgery for Intrinsic Dysfunction is
  coaptation, support, and compression of the
  damaged sphincteric unit.
• Simple suspension of the bladder neck is unlikely
  to correct the problem.
• Urethral Sling Procedures is the best to achieve
  the goal.

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Sling Operations

• A sling is put around the urethra at the bladder
  neck and either fixed around the rectus muscles
  or to the pubic bone.
• - The sling could be taken from the rectus sheath
  "Aldridge operation".
• - A nylon sling may be used "Pereyra operation".

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2. Needle Bladder Neck
Suspension Operations

• An incision is made in the vaginal wall to expose
  the bladder neck.
• A nylon suture is placed in the fascia on each
  side of the bladder neck.
• The two sutures are passed upward behind the
  symphysis pubis and are attached to the anterior
  rectus sheath.
• The cystoscope is used to be sure that the needle
  does not pass through the bladder (endoscopic
  needle bladder neck suspension).

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2. Needle Bladder Neck
Suspension Operations

• An example is Stamey operation in which two
  Dacron tubes (1 cm) are used to give support to
  the bladder neck and to avoid the sutures cutting
  through the tissues.

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ObTape transobturator sling

• September 10, 2003 new surgical implant for
  treatment of stress incontinence in women has
  been approved by the FDA.
• It was pioneered in 1999 by Emmanuel Delorme in
  France.
• Soon became popular because the procedure is
  perceived to be simpler and faster, with less
  risk of complications, than alternative
  procedures.
• In the last 2 years over 11,000 women have been
  successfully treated for stress incontinence with
  transobturator sling.

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D. Artificial Urinary Sphincter
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D. Artificial Urinary Sphincter

• Indicated when surgery fails to correct stress
  incontinence.
• The device consists of a cuff which is placed
  around the bladder neck.
• A balloon reservoir, containing fluid is placed
  in the peritoneal cavity or under the anterior
  rectus sheath, and a small pump is situated in
  one labium major.

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• Under normal conditions the cuff is full with
  fluid thus closing the bladder neck.
• When voiding is desired the pump is pressed to
  force the fluid in the cuff to go back into the
  balloon reservoir so that voiding can occur.
• The cuff then gradually refills over the next few
  minutes.

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DETRUSOR INSTABILITY (DI)
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DETRUSOR INSTABILITY

• The patient complains of urgency incontinence,
  frequency and nocturia.
• Involuntary loss of urine also occurs when the
  women sits for a long time and stands to go to
  the bathroom.
• She may pass urine with the sight or sound of
  water

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DETRUSOR INSTABILITY (DI)

• Women typically complain of urgency followed by a
  large loss of urine.
• Cystometry confirms the diagnosis.
• Involuntary detrusor contractions of 15 cm of
  water or more occur during filling of the bladder.

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TREATMENT of (DI)

• Bladder retraining drills
• The patient is asked to pass urine every hour
  during daytime and to increase the interval by 15
  minutes every week until she passes urine every
  2-3 hours.

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TREATMENT of (DI)

• 2. Drugs
• Which inhibit the contractions of detrusor muscle
  as anticholinergic drugs, tricyclic
  antidepressants, and ephedrine.
• Ephedrine stimulates alpha-adrenergic receptors
  in the internal urethral sphincter leading to
  contraction, and stimulates beta-adrenergic
  receptors in the detrusor muscle leading to
  relaxation.

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SURGICAL TREATMENT OFURODYNAMIC STRESS
INCONTINENCE

• RCOG EVIDENCE BASED GUIDELINES
• OCTOBER 2003

94

• Surgery for stress incontinence of urine has been
  performed on women for over a century.

95

• The anterior vaginal repair was the most popular
  primary procedure for stress incontinence up to
  the 1970s, but over the last 20 years the
  operation has been criticized because of high
  recurrence rates.

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• More sustained results are obtained from
  retropubic surgery.

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• Primary surgery should only be considered after
  a period of conservative treatment from
  a specialist therapist

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• The literature on surgery for stress incontinence
  is extensive but is mainly based on case
  series rather than randomized trials.

99

• Overall, 83 of women reported improvement three
  months after continence surgery, 5 had no change
  and 8 reported a worsening in their condition.

100
Surgical procedures
101
Anterior vaginal repair

• Anterior repair is less successful as an
  operation for continence than retropubic
  procedures and has been superseded by sling
  procedures.
• Anterior repair still has a role in the treatment
  of prolapse without incontinence.

A
102
Anterior vaginal repair

• Meta-analyses of heterogeneous studies suggest a
  continence rate of between 67.872.0.

A
103
Anterior vaginal repair

• The anterior colporrhaphy procedure remains in
  use, largely because of the relatively
  low morbidity of the procedure and its
  familiarity for gynecologists as an operation for
  prolapse.

A
104
Anterior vaginal repair

• The incidence of long-term voiding disorders
  following this procedure approaches zero.
• Long-term results decrease with time, such that a
  63 continence rate at one year of follow up fell
  to 37 at five years of
  follow up.

A
105
Anterior vaginal repair

• The view of the American Urological Association
  is that anterior repairs are the least likely of
  the four major operative categories (anterior
  repair, suburethral sling, colposuspension,
  long-needle suspension) to be efficacious in the
  long term.

A
106
Burch colposuspension

• Burch colposuspension is the most effective
  surgical procedure for stress incontinence, with
  a continence rate of 8590 at one year.
• The continence rate falls to 70 at five years
  this shows better longevity than other methods of
  treatment.

A
107
Burch colposuspension

• Voiding difficulty has been reported in a mean of
  10.3 of women after colposuspension (range
  227).
• De novo detrusor overactivity has been described
  in a mean of 17 women (range 827).
• Genitourinary prolapse (enterocele, rectocele)
  has been reported in follow up at five years in
  an average of 13.6 women
  (range 2.526.7).

A
108
Burch colposuspension

• Ureteric damage has been reported.
• There was no reported mortality as a direct
  consequence of the procedure.
• The continence rate after Burch colposuspension
  falls if previous continence surgery has been
  performed.
• In one study the continence rate fell from 84
  for a primary procedure to 63 for secondary
  surgery

A
109
Burch colposuspension

• A Cochrane review has examined the place of Burch
  colposuspension among other continence procedures
  and concluded that
• open colposuspension is the most effective
  surgical treatment for stress incontinence,
  especially in the long term.

A
110
Burch colposuspension

• Burch colposuspension is more effective than
  needle suspension and provides a similar
  subjective continence rate to laparoscopic
  colposuspension (85100 after 618 months of
  follow-up).

A
111
Alternative suprapubic surgery

• The role of other suprapubic operations such as
  MarshallMarchetti Krantz , paravaginal repair
  and laparoscopic colposuspension, is unclear.

B
112
Marshall Marchetti Krantz (MMK)

• (MMK) retropubic procedure was a common
  anti-incontinence procedure between195090s and
  Krantz described a personal series of 3861 cases
  with a follow-up of up to 31 years and a 96
  subjective continence rate.

A
113
MarshallMarchettiKrantz (MMK)

• The mortality was 0.2, with a 22 overall
  complication rate.
• This operation has now fallen into disuse.

A
114
MarshallMarchettiKrantz (MMK)

• A characteristic complication of MMK was osteitis
  pubis, which occurs in 2.5 of patients who
  undergo a MMK procedure.
• The operation was less successful than Burch
  colposuspension at correcting a cystocele.

A
115
Laparoscopic colposuspension

• Laparoscopic colposuspension has been the subject
  of several case series and cohort studies, which
  show similar continence rates between
  laparoscopic and open Burch colposuspension.

A
116
Laparoscopic colposuspension

• There were no significant differences for
  postoperative detrusor overactivity or voiding
  difficulty.

A
117
Laparoscopic colposuspension

• There were trends towards a
• higher complication rate and
• longer operative times,
• lower intraoperative blood loss,
• less postoperative pain,
• shorter need for catheterization,
• shorter hospital stay and
• earlier return to normal activities

A
118
Laparoscopic colposuspension

• Despite a quicker recovery, the
  operation takes longer to perform, is associated
  with more surgical complications and is more
  expensive.
• It is likely to be performed by surgeons highly
  skilled in both continence and laparoscopic
  techniques.

A
119
Needle suspension procedures

• Needle suspension procedures should not be
  performed initial success rates are not
  maintained with time and
• The risk of failure is higher than for retropubic
  suspension procedures.

A
120
Needle suspension procedures

• Multiple suspension procedures have been
  described in the past.
• The first procedure was described by Peyrera and
  numerous procedures have subsequently evolved
  from this, including the Stamey procedure, using
  suspending sutures and patch materials.

A
121
Needle suspension procedures

• Long-term follow up of the percutaneous needle
  procedure was only
• 5 cured , with
• 12 significantly improved and
• 83 considered the operation a failure.

A
122
Needle suspension procedures

• Needle suspensions were more likely to fail than
  open retropubic procedures and there were more
  perioperative complications in the needle
  suspension group (48 compared with 30).
• Needle suspensions may be as effective as
  anterior repair but carry a higher morbidity

A
123
Sling procedures

• Suburethral sling procedures were developed
  initially in the 1880s.
• Numerous authors have subsequently modified these
  procedures.

C
124
Sling procedures

• Aldridge used rectus sheath strips , the success
  rate recorded in the literature would appear to
  range between 64 and 100, with a mean
  continence rate in the region of 86.

C
125
Sling procedures

• Sling procedures, using autologous or synthetic
  materials, produce a continence rate of
  approximately 80 and an improvement rate of 90,
  with little reduction in continence over time.
• Only one synthetic sling procedure (tension-free
  vaginal tape) has been subjected to randomized
  study to date.

A
126
Sling procedures

• Numerous materials are available for use in a
  suburethral sling.
• As a generalization, autologous material is
  associated with a greater continence rate and
  fewer complications than either cadaveric
  material or synthetic materials.

A
127
Sling procedures

• Autologous rectus fascia and fascialata are
  probably the most common materials in use.

A
128
Sling procedures

• Synthetic material tends to be associated with a
  risk of erosion and sinus formation.

A
129
Sling procedures

• Modifications designed to achieve greater
  stabilization, such as anchorage to the pubic
  bone, are associated with good results in the
  short term but carry a long-term risk of
  osteomyelitis at the site of anchorage.

A
130
Sling procedures

• When compared with colposuspension procedures,
  the suburethral sling carries a similar success
  rate.

A
131
Sling procedures

• The intermediate and longer-term results for
  suburethral slings suggest that the ten-year
  continence rate is not dissimilar from the
  one-year continence rate.

A
132
Sling procedures

• The American Urological Association considered
  that Retropubic suspensions and slings are the
  most efficacious procedures for long-term success
  based upon cure/dry rate.
• However, retropubic suspensions and sling
  procedures are associated with slightly higher
  complication rates, including postoperative
  voiding difficulty and longer convalescence.

A
133
Sling procedures

• The Second International Consultation on
  Incontinence concluded that suburethral slings
  represented an effective procedure for genuine
  stress incontinence in the presence of previous
  failed surgery.

A
134
TVT

• The Prolene tension-free vaginal tape (TVT) is
  relatively new, although increasing numbers of
  cohort studies of its use are being reported.
• The originator of the procedure reports that, at
  three years, 86 of women were completely
  cured, while a further 11 were significantly
  improved.

A
135
TVT

• The majority of women are potentially treatable
  without general anaesthesia and on a day-case
  basis.
• Between 3 and 15 of women developed symptoms
  compatible with the onset of de novo detrusor
  overactivity.

A
136
TVT

• Short-term voiding disorder is described in 4.3
  of women, although longer term voiding disorder
  does not appear to be a specific feature.

A
137
TVT

• There have been a few individual case reports of
  urethral erosion, sometimes several years after
  surgery.
• There is a need for long-term results for this
  procedure.

A
138
TVT

• Despite being more expensive than
  colposuspension, the reduction in
  hospital stay makes the procedure cost
  effective

A
139
Injectable agents

• Injectable agents have a lower success rate than
  other procedures a short-term continence rate of
  48 and an improvement rate of 76.
• Long term, there is a continued decline in
  continence.

B
140
Injectable agents

• The procedure has a low morbidity and may have a
  role after other procedures have failed, e.g.
  when a diagnosis of intrinsic sphincter
  deficiency is made.

C
141
Injectable agents

• The bulking agents (collagen, Teflon fat,
  silicone, Durasphere ) are injected in a
  retrograde (more common) or antegrade fashion in
  the periurethral tissue around the bladder neck
  and proximal urethra.

C
142
Injectable agents

• Follow up was between three months and two years,
  (mean of 12 months).
• The cure rate, defined as completely dry, was
  48.
• The success rate (defined as dry or improved) was
  76.

C
143
Injectable agents

• For silicone Radley et al. showed cure or
  improvement in 60 in a prospective cohort of
  women with recurrent stress incontinence on a
  19-month follow-up.
• Detrusor overactivity was an important cause of
  failures in this study.

C
144
Injectable agents

• RCTs are needed for bulking agents.
• The lack of morbidity associated with the bulking
  agents leads some people to believe that they
  should be more meaningfully compared with
  conservative therapy such as pelvic floor
  physiotherapy.

C
145
Artificial sphincters

• Artificial sphincters can be successfully used
  after previous failed continence surgery but have
  a high morbidity and need for further surgery
  (17).

B
146
Preoperative management

• It is recommended that women undergoing surgery
  for urodynamic stress incontinence should have
  urodynamic investigations prior to treatment
  (including Cystometry).

147
Preoperative management

• Prior to performing assess objectively the type
  of incontinence and the presence of any
  complicating factors such as voiding difficulty
  or detrusor overactivity, which may affect the
  surgical decision

148
Preoperative management

• Surgery should be performed by a surgeon who has
  been trained in the operation and who has a
  caseload that enables him or her to provide a
  suitable level of expertise, especially when any
  repeat surgery is considered.

149
Thank you